A PILOT STUDY OF WEARABLE DEVICES TO DETECT SEPSIS

J YO1, C KARSCHIMKUS2, S CHRISTOV3, F VOLPATO4, P CHAMPION DE CRESPIGNY5, SG HOLT6
1Melbourne Health, Parkville, Australia, 2Melbourne Health, Parkville, Australia, 3Melbourne Health, Parkville, Australia, 4Freelance Signal Analyst, Melbourne, Australia, 5Melbourne Health, Parkville, Australia, 6Melbourne Health, Parkville, Australia

Aim: Health monitoring devices are popular, accepted and purchased by many patients. We assessed the feasibility of a watch device to detect infection.
Background: Infection is an important cause of morbidity and mortality among patients with kidney disease, and early identification and treatment reduces mortality. Diagnosis remains a challenge, but fever is a relatively reliable sign.
Methods: We conducted a single-center prospective cross-sectional pilot study of in-patients to demonstrate proof of concept. Patients randomly admitted under the nephrology unit between August 2017 and April 2018 were consented to wear a monitoring device. Participants wore a clinical grade device that measured peripheral temperature at the wrist (Empatica E4) along with other physiological variables, and we report early analysis of temperature (t) alone. We classified patients as having sepsis, no sepsis and/or treated sepsis and examined how well t correlated with the presence of sepsis.
Results: 104 patients underwent data recording and 82 patients had complete data. 58 patients had no sepsis,15 patients had sepsis and 9 patients had treated sepsis. None of the 41 patients who had at least 84% of readings <35°C had active sepsis. Of the 41 patients with greater than 16% of readings ≥35°C, 15 had sepsis (PPV=21%, NPV=100%). 9/10 patients who had >0.5% of readings ≥37°C had sepsis (PPV=52%, NPV=92%) (1 false positive was admitted with limb ischaemia after occlusion of a vascular graft).
Conclusion: Peripheral temperature measurement may add value to sepsis detection. Further data analysis is underway to refine the detection algorithm. We hope to be able to incorporate such algorithms into a consumer device that can continuously monitor and signal the user of impending infection.


Biography:
Dr. Jennifer Yo is currently a final year Advanced Nephrology Trainee at Melbourne Health.

THE ENDOTHELIAL GLYCOCALYX IS DAMAGED WITH WORSENING KIDNEY DISEASE AND CORRELATES WITH MARKERS OF ENDOTHELIAL DYSFUNCTION

H LIEW1,2, M ROBERTS1,2, L MCMAHON1,2
1Department of Renal Medicine, Box Hill, Australia, 2Monash University, Melbourne, Australia

Background: Damage to the endothelial glycocalyx (EG) is an early indicator of vascular damage and a potential marker of endothelial dysfunction. EG damage is detected by biochemical markers and an increase in the perfused boundary region (PBR) in the sublingual capillaries using the novel Glycocheck device.
Aim: We aimed to assess EG damage in patients with kidney disease by measuring the PBR and biochemical markers of EG, and correlating it with markers of endothelial dysfunction (ED) and microalbuminuria.
Methods: Healthy controls, CKD patients (eGFR 15-60mL/min), dialysis patients, and kidney transplant recipients had blood taken for syndecan-1 (EG marker), vascular cell adhesion molecule, VCAM-1 (marker of ED), urine for albumin:creatinine ratio (uACR) and a PBR measurement performed.
Results: Median (interquartile range) ages were 35 (22-69), 71 (37-90),  67 (25-82) and 55 (34-77), p<0.001 years in the control (n=28), CKD (n=33), dialysis (n=33) and transplant (n=30) groups, respectively. Mean eGFR was 89±6, 31±11, 7±4, and 59±14 mL/min (p<0.001) and median uACR was 0.4 (0-2), 37 (0-730), 44 (5-642) and 5 (0-35) mg/mmol (p<0.001), respectively. Serum markers of EG damage and ED were highest in the dialysis group. Median syndecan-1 levels were 26 (10-146), 39 (18-160), 81 (40-530), and 38 (24-67) ng/L (p<0.001), respectively. Mean VCAM levels were 675±211, 1146±468, 1658±552, and 927±254 ng/mL (p<0.001), respectively. There was no difference detected in PBR (2.04±0.31, 2.05±0.28, 2.01±0.35, and 2.06±0.28µm, respectively, p=0.925). Syndecan-1 positively correlated with VCAM (r=0.434, p<0.001) and uACR (r=0.403, p<0.001).
Conclusion: Markers of the EG and ED are closely correlated, and are highest in dialysis patients, followed by CKD and transplant patients compared to controls. No difference in PBR was detected.


Biography:
Renal Research Fellow

FLUCLOXACILLIN AND PARACETAMOL INDUCED PYROGLUTAMIC ACIDOSIS

S KUMAR1, M RAY1
1Gosford Hospital , North Gosford, Australia

Background: Pyrogluamic acid (also known as 5- oxoproline) accumulation is a rare cause of high anion gap metabolic acidosis. The combination of paracetamol and flucloxacillin has been implicated in a number of case reports. Paracetamol depletes glutathione levels which increases 5-Oxoproline production. Concomitant use of flucloxacillin inhibits 5-oxoprolinase that is required to metabolize the 5-Oxoproline.
Case Report: A 78 year old female with an extensive past medical history presented to local Emergency Department with headache, back pain, and general malaise for 4 days. The findings on physical examination were fever, tachycardia and back tenderness. A septic screen was performed and Gentamicin and Flucloxacillin were administered for presumed sepsis. Blood cultures grew methicillin sensitive Staphylococcus Aureus.Her subsequent workup demonstrated spondylodiscitis and infective endocarditis on the mitral and aortic valves. She continued to received Flucloxacillin, and her regular medications including paracetamol. During the admission the serum bicarbonate declined from 25mmol/L on the day of admission to 12mmol/L on day 34 and the patient became confused with an altered level of consciousness. Blood gas analysis demonstrated a raised anion gap metabolic acidosis. Investigation for common causes of raised anion gap acidosis yielded no diagnosis. A comprehensive urine metabolic screen was requested to assess for elevated 5-oxoproline levels (also known as pyroglutamic acid). The 5-oxoproline level was significantly raised. Flucloxacillin and paracetamol were ceased and the patient was give N-Acetyl Cysteine. Shortly after the diagnosis was made the patient and family elected to withdraw active care.
Conclusions: Pyroglutamic Acidosis should be considered as a cause of high anion gap metabolic acidosis in patients treated with flucloxacillin and paracetamol.


Biography:
Dr Kumar is a Nephrologist who practices General Nephrology in Gosford,NSW with particular expertise in peritoneal dialysis. Dr Max Ray is a Basic Physician Trainee.

 

BONE SCINTIGRAPHY AS A MODALITY TO MONITOR DISEASE ACTIVITY OF CALCIPHYLAXIS IN A PATIENT WITH END-STAGE KIDNEY DISEASE SECONDARY TO DIABETIC NEPHROPATHY

J CHUA1, A HANNAH1, D BARIT1,2, D LANGSFORD1,2
1Northern Health, Epping, Australia, 2University of Melbourne, Parkville, Australia

Background: A diagnosis of calciphylaxis is often made clinically. Bone scintigraphy has been considered as a diagnostic tool for calciphylaxis. We report a case demonstrating the use of bone scintigraphy to diagnose and guide the management of calciphylaxis.
Case Report: A 60-year-old female suffering with pre-dialysis end-stage kidney disease secondary to diabetic nephropathy reported painful subcutaneous nodules in her legs. She was commenced on dialysis due to a concern the lesions were calciphylaxis. Bone scintigraphy performed had findings consistent with calciphylaxis with tracer uptake in subcutaneous tissues, which extended well beyond clinical margins of the nodules.  The patient was commenced on sodium thiosulphate, had increased dialysis frequency with a low calcium dialysate, and had her calcium-containing phosphate binders replaced by non-calcium-based binders.  In two months, the patient‘s subcutaneous nodules reduced and her pain improved and repeat bone scintigraphy demonstrated interval improvement. Six months after diagnosis, the patient had complete resolution of her calciphylaxis both clinically and on repeat bone scintigraphy.  Her calciphylaxis treatment was ceased and she returned to a standard dialysis protocol. Six months later, repeat bone scintigraphy remained normal, indicating no evidence of sub-clinical recurrence.
Conclusions: This case provides further evidence of the potential utility of bone scintigraphy to diagnose calciphylaxis, to determine its severity and help direct management. Bone scintigraphy demonstrated calciphylaxis can extend both spatially and temporally beyond the clinical findings. Further study is warranted to assess the potential use of bone scintigraphy for diagnosis and subsequent management of calciphylaxis.


Biography:
Dr. Justin Chua is a registrar at the Austin and Northern Hospital currently undertaking his advanced training in General Medicine. His aim is to dual-train and specialise in both Nephrology and General Medicine. He has previously worked as an unaccredited renal registrar at the Austin and Northern Hospitals.

GLOMERULAR, MESANGIAL, AND TUBULAR CYTOPLASMIC FIBRILLARY INCLUSIONS IN A PATIENT WITH MYELOMA

E CHUNG1, K MCILROY1, C FUNG2, S SESHAN3, P COLEMAN4
1Royal North Shore Hospital, Sydney, Australia, 2Concord Repatriation General Hospital, Sydney, Australia, 3Weill Cornell Medical College , New York, United States of America, 4Manly Hospital, Sydney, Australia

Background: Plasma cell dyscrasias are characterised by overproduction of monoclonal proteins which can cause a wide range of kidney diseases. Whilst the majority of pathogenic light-chains are tubulopathic, in a minority of cases reabsorption of light-chains in the proximal tubules can cause intracellular crystal deposits or inclusion bodies. The accumulation of fibrillary cytoplasmic inclusions causing proximal tubulopathy has only been described in two previous cases. We report a case of persistent proteinuria without acute kidney injury, with abnormal accumulation of cytoplasmic fibrillary inclusions on kidney biopsy.
Case Report: A 59-year old man with IgA κ paraproteinemia was investigated for worsening proteinuria (2.4g to 4.8g in 24 hours) with stable renal function (serum creatinine 110 µmol/L) from 2012 to 2014. A renal biopsy showed extensive tubular vacuolation and focal fibrillar structures on the Masson stain, suggesting intracytoplasmic fibrillary deposition related to the known paraproteinemia. Insitu hybridisation and immunoperoxidase staining for κ and λ light chains were negative. Electron microscopy showed abnormal fibrils (10nm diameter) in the lysosomes of mesangial cells, glomerular endothelial cells and tubular cells. A bone marrow aspirate showed 46% monoclonal plasma cells. The diagnosis of multiple myeloma with light chain-associated proximal tubulopathy was made. Five rounds of cyclophosphamide, bortezomib and dexamethasone chemotherapy followed by a syngeneic stem cell transplant was performed in 2015, resulting in clinical remission of his multiple myeloma and improvement of his proteinuria to 0.36g/day by 2017.
Conclusions: Accumulation of fibrillary material on electron microscopy, while rare, is strongly suggestive of plasma cell dyscrasias and should direct clinicians to perform further haematological investigations to confirm the diagnosis of plasma cell dyscrasias.


Biography:
Edmund Chung is currently a first year renal advanced trainee in the East Coast Network, NSW. He completed his undergraduate BMed MD at UNSW and postgraduate MMed (ClinEpi) at the University of Sydney. He has performed systematic reviews with the Cochrane Kidney and Transplant group and is passionate about better understanding how to limit the progression of chronic kidney disease.

CHARACTERISTICS OF THE SCREENED STUDY POPULATION IN THE PREVENT-ADPKD TRIAL

ATY WONG1, C MANNIX1, J ZHANG1, DCH HARRIS1,2, VW LEE1,2, K SUD2,3, C WOOLNOUGH4 GK RANGAN1,2,3 ON BEHALF OF THE PREVENT-ADPKD TRIAL GROUP.

1Centre for Transplant and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, NSW; 2Department of Renal Medicine, Westmead Hospital, Western Sydney Local Health District, Sydney, NSW; 3Nepean Clinical School, Department of Renal Medicine, Nepean Hospital, University of Sydney, Sydney, NSW; 4Chemical Pathology, Royal Prince Alfred Hospital, Camperdown, NSW

Aim: To describe the characteristics of adults with autosomal dominant kidney disease (ADPKD) screened in the PREVENT-ADPKD trial.

Background: PREVENT-ADPKD is an investigator-initiated, multi-centre, parallel group randomised controlled trial designed to determine the efficacy of water intake prescribed to reduce urine osmolality to <270 mosmol/kg and systemic levels of vasopressin to prevent the progression of height-adjusted total kidney volume (ht-TKV) in ADPKD.

Methods: Adults (18-65yrs) diagnosed with ADPKD with CKD-EPI eGFR ≥30 mL/min/1.73m2 and able to complete magnetic resonance imaging (MRI) were included. Data from the first 50% of intended recruitment target (n=90) were analysed.

Results: The mean±SD age, gender, BMI, serum creatinine and eGFR of the cohort was 43±11 yrs, M:F 53:47%, 26±7 kg/m2, 95±32 µmol/L and 75±17 ml/min/1.73m2 respectively. The mean ht-TKV was 806±530 ml/m with the distribution of estimated annual TKV growth rate categories of <1.5%/yr (1A), 1.5-3.0%/yr (1B), 3-4.5%/yr (1C), 4.5-6%/yr (1D) and >6%/yr (1E) being 11.7, 23.3, 29.9, 27.2 and 7.8% respectively. The mean blood pressure (BP) was 133+82 mm Hg, and 13.6% had normal BP, 49% high-normal BP, 31% Grade 1 hypertension and 7% Grade 2 hypertension. Ht-TKV had a moderate correlation with log-transformed baseline serum copeptin (r=0.46, P<0.05) and serum creatinine (r=0.69, P<0.01) but by multi-variate analysis only the latter was a significant predictor. There were no baseline differences between gender except, height, serum creatinine and body weight which were all higher in men (P<0.05)

Conclusions: The screened population has similar characteristics to other clinical trial cohorts. Prognostic enrichment (exclusion of Mayo Subclass IA which constitute ~10% of screened population) will be used to select patients with a high-risk of progression.

TOTAL NEPHRON NUMBER DECREASES WITH THE STAGE OF CHRONIC KIDNEY DISEASE – A STUDY IN JAPANESE SUBJECTS

G KANZAKI1,2, VG PUELLES3, LA CULLEN-MCEWEN1, Y OKABAYASHI2, N TSUBOI2, A SHIMIZU4, T YOKOO2, JF BERTRAM1

1Cardiovascular Program, Monash Biomedicine Discovery Institute and Department of Anatomy and Developmental Biology, School of Biomedical Sciences, Monash University, Melbourne, Victoria; 2Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan; 3Department of Nephrology and Immunology, RWTH Aachen University, Aachen, Germany; 4Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan

Aim: The aim of this study was to evaluate the relationship between nephron number and the stage of chronic kidney disease (CKD) in Japanese adults.

Background: It has been proposed that a nephron deficit marks the risk for CKD. We have previously shown that nephron number predicts eGFR. However, changes in total nephron number across the stages of CKD have not previously been reported. In this study we assessed total nephron number and clinicopathological findings in Japanese subjects in order to determine the structural and functional changes associated with nephron loss in each CKD stage.

Methods: Kidneys from 59 Japanese subjects were collected at Nippon Medical School, Tokyo, Japan during autopsy and were divided into three groups; CKD stage 1 (n=13, eGFR>90 mL/min), CKD stage 2 (n=25, eGFR 89-60 mL/min), and CKD stage 3-4 (n=21, eGFR 60-15 mL/min). Total nephron number and mean glomerular volume were estimated by design-based stereology. Single nephron eGFR (SNeGFR) was calculated as eGFR divided by two times the number of non-sclerotic glomeruli.

Results: Total nephron number was significantly lower in CKD stage 3-4 (293,558±89,716; mean±SD; P<0.001) than in CKD stage 1 (631,980±159,755) and CKD stage 2 (504,716±130,342. Kidney weights and cortical volumes were similar in the three groups. Glomeruli were larger in CKD stage 3-4 (P<0.001) than in CKD stages 1 and 2. No differences in total glomerular volume (combined volume of all non-sclerotic glomeruli) or SNeGFR were observed between the three groups.

Conclusions: Compared with subjects with eGFR>60 mL/min, CKD stage 3-4 patients had an apparent nephron deficit, with glomerular hypertrophy partially compensating for the nephron loss.

INFLUENCE OF TIMING AND PATIENT CHARACTERISTICS ON OUTCOMES OF A COMPREHENSIVE PRE-DIALYSIS PROGRAMME IN WESTERN SYDNEY

B JEFFREY1, T SMOLONOGOV2, L KAIRAITIS1,2

1School of Medicine, University of Western Sydney, NSW; 2Western Renal Service, Sydney, NSW

Aim: To investigate how patient characteristics and eGFR at referral to a comprehensive pre-dialysis programme influence access planning and home dialysis uptake in Western Sydney.

Background: Although pre-dialysis patient education and counselling is recommended to improve patient outcomes, optimal timing of this intervention remains unclear. Western Renal Service established a comprehensive pre-dialysis education programme in 2005 to facilitate informed dialysis modality choice and timely access planning.

Methods: Patients referred to the programme between 2005-15 prior to starting dialysis were identified. Two primary outcomes were considered: temporary haemodialysis catheter use at dialysis commencement and uptake of home dialysis. The influence of patient characteristics and eGFR at the point of referral was examined using Logistic regression analysis.

Results: 947 patients referred to the programme subsequently commenced dialysis at the time of audit; 30% with temporary haemodialysis access. Factors independently associated with temporary haemodialysis catheter use at dialysis commencement were lower eGFR at referral, presence of diabetes and patient ethnicity.

73% of patients undertook a home-based dialysis therapy in follow-up. Patient ethnicity, increased age and a diagnosis of diabetes were independently associated with a lower uptake of home-based dialysis.

Conclusions: High uptake of a home-based dialysis modality was achieved in patients referred to this programme however later referral was associated with a greater risk of starting dialysis with temporary access. Patient ethnicity and the presence of diabetes should influence the timing of referral to a pre-dialysis programme.

THE USUAL DIET OF AN AUSTRALIAN POPULATION OF ADPKD PATIENTS

J ZHANG1,2, C MANNIX1, C WOOLNOUGH3, GK RANGAN1, A RANGAN2, ATY WONG1

1Centre for Transplant and Renal Research, Westmead Institute for Medical Research, University of Sydney, Westmead, NSW; 2School of Life and Environmental Sciences, Charles Perkins Centre, University of Sydney, Camperdown, NSW; 3Department of Chemical Pathology, Royal Prince Alfred Hospital, Camperdown, NSW

Aim: To analyse the usual food and nutrient intake of an Australian population of patients with autosomal dominant polycystic kidney disease (ADPKD).

Background: Dietary factors have been associated with cyst growth, renal function and disease progression.

Methods: A structured diet history interview was used to obtain usual intake over 3 months from 29 participants (21-61 y). Nutrient intakes were compared to the KHA-CARI ADPKD Diet and Lifestyle Management Guidelines. A twenty-four-hour urine collection and blood sample were collected to measure urinary sodium and serum copeptin (B.R.A.H.M.S. assay).

Results: Mean (SD) daily nutrient intakes were: energy 8529 (2338) kJ; protein 1.5 (0.7) g/kg body weight; sodium 97 (43) mmol; caffeine 119 (90) mg and fluid 3154 (1403) g. Seventy-nine percent of participants exceeded protein recommendations (1.0 g/kg body weight/d); 31% (41% males, <1% females) exceeded sodium recommendations (100 mmol/d); and 17% exceeded caffeine recommendations (200 mg/d). Average total fluid intake was comprised of 46% plain water, 28% other beverages and 26% solid food. Recommendations from the Australian Dietary Guidelines (ADG) for total fluid (from food and beverages) and for fluid from beverages only were not met by 62% and 66% of participants, respectively. Consumption of vegetables and dairy was low with 79% and 90% not meeting the ADG recommended serves, respectively. Excluding Stage 3 CKD patients, mean 24-h urinary sodium excretion (145 (71) mmol) had a weak correlation with reported sodium intake (r=0.363; P=0.089) and a strong correlation with serum copeptin (r=0.772; P<0.001).

Conclusions: The usual diet of ADPKD patients does not comply with current recommendations. Targeted interventions to reduce protein and sodium intake, increase consumption of vegetables and dairy and increase fluid intake are warranted.

“INTERVENTIONAL DAY UNIT” – A SOUTH WESTERN SYDNEY LOCAL HEALTH DISTRICT (SWSLHD) OUTPATIENT SERVICE INITIATIVE. REDESIGNING RENAL SERVICE DELIVERY

J.K. WONG1, I DE GUZMAN1, A MAKRIS1, T.S. SPICER1, M LI DONNI1

1Liverpool Hospital, SWSLHD, Sydney, Australia

Aim: Examine the impact and cost-benefit of implementation of this model of care which commenced a four bedded/chair area within the Satellite dialysis unit, operating three days a week. Existing management and administration services were utilised. Funding was provided through capturing of billing opportunities and generation of revenue.

Background: Many renal patients require day only procedures or treatment including: biopsies, access procedures including insertion of Tenckhoff catheters and tunneled vascular catheters requiring pre and post procedural care, and salt, iron and chemotherapeutic infusions. With general hospital ambulatory services increasingly difficult to access, and increasing demand from renal patients in the South-Western Sydney Local Health District (SWSLHD) resulting in delayed diagnostic and therapeutic interventions an interventional day unit was developed.

Methods: Retrospective review of episodes of care and funds generated from October 2015-October 2016 in the interventional day unit

Results: From the introduction of the service, 432 outpatient procedures and treatments were performed in the first year, and an additional 41 procedures were conducted on “inpatients” which could not be billed. The revenue generated was greater than the service cost. Revenue exceeded $104,000. The cost of the workforce was $95,663.36 – a net gain of over $8,000. At least 163 inpatient admissions were avoided by this implementation, a further cost saving to the health service.

Conclusions: The renal interventional day unit has been innovative in providing service delivery to renal outpatients in the SWSLHD. This self-funded initiative incorporated existing services successfully and provided expeditious, specialized care and services and access to treatment. Additionally, the avoidance of unnecessary admissions and/or delayed discharges and streamlining patient journey into dialysis pathways was achieved.

1236

About ANZSN

The ASM is hosted by Australian and New Zealand Society of Nephrology.

The aims of the Society are to promote and support the study of the kidney and urinary tract in health and disease, and to ensure the highest professional standards for the practice of nephrology in Australia and New Zealand.

Conference Managers

Please contact the team at Conference Design with any questions regarding the Annual Scientific Meeting

© 2015 - 2016 Conference Design Pty Ltd